It’s time for the NHS to remember its dead, starting with restorative justice.
A year ago today, the Gosport Independent Panel published its damning report into the deaths of hundreds of people, whose lives were shortened by the prescription of opiates without medical justification.
The report should be required reading on any medical school curriculum. It sets out how staff whistleblowers were ignored or suppressed and how public authorities studiously looked the other way. Worse, the report sets out the failure of some of those authorities to cooperate fully with the inquiry to this day. The General Medical Council is criticised for a lack of transparency and a tendency to over-redact material. But the rot goes all the way to the top. Sir Normal Lamb told BBC Radio 4 how civil servants at the Department of Health had resisted his efforts, as a Minister of the Crown, to read an earlier report by Professor Baker which had laid bare the problems at Gosport. As Sir Norman put it on Radio 4’s The World Tonight, the Gosport scandal raises “profound questions for public authorities”.
Those questions start with the Department of Health and its role in suppressing “bad news”, whether directly, or by facilitating supposedly arms-length bodies (e.g. NHS England or individual hospital Trusts). Gosport is not a one off, or egregious exception. It’s the culmination of a suppressive culture, curdled at the top.
Evidence of that culture abounds. Consider the regulators: The Gosport Panel’s Report lays bare the failure of the General Medical Council (GMC) to protect the public from poor medical practice; Whorlton Hall demonstrates the repeated failure of the Care Quality Commission (CQC) to protect vulnerable adults from abusive staff and inadequate care providers; in my own whistleblowing case, the CQC assured the Department of Health that my reports about children’s deaths were unfounded, even when the CQC knew the exact opposite: that the Royal College had substantiated several of my concerns and made 24 recommendations to be implemented within months.
Regulators aside, individual Trusts have used public cash to have lawyers suppress reports – protecting senior staff rather than promoting public safety.
Yesterday’s Health Service Journal reported on the suppression of such a report on children’s cancer services at the Royal Marsden Hospital. Celebrity Trusts, like this one and like Alder Hey, seem to find it hard to admit failings – for fear of reputational injury. For want of candour, supposed centres of excellence can readily incubate areas of really poor practice.
Alder Hey’s former Chair, David Henshaw, flatly denied to Parliament all and any concerns about a series of children’s cases. In truth, his Trust had accepted the findings of a Royal College report showing children had died or been harmed avoidably. But he and Alder Hey CEO Louise Shepherd redacted the Royal College report, saving the embarrassment of facing their falsehoods more publicly.
Remarkably, Alder Hey’s CEO continues to spend lavishly on lawyers to defend her position, even when there are really only two conclusions. Either she denied all concerns unwittingly and unaware of the Royal College findings; or she denied all concerns, knowing her denial to be false. At the very best, she’s shown breathtaking incompetence and a disregard for Royal College findings. One of the children harmed on Shepherd’s watch was Caitlyn Parry. I’d blown the whistle on her death and the failures leading up to it. The Trust battled Caitlyn’s mum, using lawyers, for some seven years, before finally paying up.
Gosport is a War Memorial Hospital, named in honour of the dead who’d served. It’s time for the NHS to remember its dead. Learning via a programme of restorative justice might be a fitting monument.
Jesudason Appeal 